Page 1 of 5

Medical Withdrawal Petition Questionnaire

For detailed instructions, please visit www.dso.ufl.edu/care

12997906 _______________ UFID 2134 sw 14th st.

Street Address Email Address:

Avery _________________________ Last Name

Apt# City

Jake ________________________ First Name FL

State

T ________ MI 32608
Zip Code

2013/Mech Eng ______________ Class/College

Gainesville

averyangler@ufl.edu ______________________________________________________

239.777.5648 __________________________________________________ Phone Number:

Retroactive Semester Medical Withdrawal
* Petitioning to withdraw from a past semester(s) *

Please check the box for the type of withdrawal you are requesting to petition and indicate the semester(s) & year(s). (FOR EXAMPLE: Fall 2011, Spring 2012, Summer A 2012, Summer B 2012, Summer C 2012)
* Withdrew from all classes by the withdrawal deadline *
MWD

Medical Withdrawal by Deadline

SEMESTER/YEAR__________________________________ EXAMPLE: Spring 2012, Summer B 2012 * Dropped individual course(s) by the withdrawal deadline *

RMP

SEMESTER/YEAR_________________________________ EXAMPLE: Fall 2011, Summer B 2011 * Petitioning to withdraw from a past course(s)*

Medical Drop by Deadline

Retroactive Semester Medical Drop

MDD

SEMESTER/YEAR__________________________________ EXAMPLE: Spring 2012, Summer B 2012

SEL

See attached SEMESTER/YEAR_________________________________ EXAMPLE: Fall 2011, Summer B 2011

If you are petitioning for individual course(s), please list the course prefix, number and section number below. EXAMPLE: CHM 2045, section 3298 Reason for Medical Withdrawal/Drop: Physical Psychological Death of Immediate Family Other __________________________

Once you complete this entire Medical Withdrawal Questionnaire, please submit this packet with your current medical documentation to the Dean of Students Office. Once received, the Medical Withdrawal Committee or University Petitions Committee may ask for additional documentation. If a retroactive drop or withdrawal is approved for courses taken since the start of the Fall 2009 term for which you received Bright Futures funding, you will be required to repay the Bright Futures funding used per F.S.1009.53. It is important to note that the Medical Withdrawal Committee believes all petitions should normally be submitted within six months after the end of the term during which the medical event occurred. If you are submitting this petition outside of that timeframe, it is particularly critical that you specify the reasons for this delayed request. However, per BOG Regulation 7.002(11), a written appeal for a refund or other appeal action must be submitted to the University within six (6) months of the close of the semester to which the refund or other appeal action is applicable. You may check your petition status online at www.isis.ufl.edu. All documentation is subject to verification. Any submission of false or fraudulent information or documentation will result in Student Code of Conduct charges.

I hereby certify that the information and documentation that I have submitted for this petition is true and accurate to the best of my knowledge. _______________________________________________ Student's Signature _______________________________________ Date

***********************************************COMMITTEE USE ONLY*************************************************

Committee Action: Withdrawal Date: Notes/Comments: Approved Denied Deferred

________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

Authorized Signature

________________________________

Date

________________________________

Name _________________________ UFID ____________________________

Page 2 of 5

For detailed instructions please visit www.dso.ufl.edu/withdrawals Please type your answers to the following questions in order for the committee to review the impact of your medical situation on your academic performance in the semester/course(s) that you are petitioning. What did you experience that impacted you during the semester in question? Please provide a medical diagnosis if applicable.

Medical Withdrawal Petition Questionnaire

I was diagnosed with ADHD for the first time in college, I began taking the proper medication in Fall of 2011, but didn't begin receiving accommodations for extended exam time until it was suggested to me by the head of the mechanical engineering department just before the fall semester of 2012. Because of the extremely high weighing of exams in engineering course grades, my lack of proficiency in test taking due to ADHD significantly effected my grades early on.

When did the presenting issues begin and how did they impact your academic performance?

I've had exam time restriction issues my whole life, but it wasn't until I began taking engineering courses that my exam issues were noticed and associated with ADHD. At the UF wellness center they informed me that ADHD often goes undiagnosed until college, due to personal overcompensation through various means like drinking large quantities of espresso, energy drinks, etc. In the majority of engineering courses at UF, the grade is highly dependent on exam scores. These exam scores usually make up 70% or more of an entire semester's grade. Without accommodations like I am now receiving, my grades were severely impacted.

Name _________________________ UFID ____________________________

Page 3 of 5

What type of assistance or intervention did you receive? Please include dates of attendance.

During the summer of 2011 I was diagnosed with ADHD by the University of Florida wellness center. Over the span of several months, into the fall semester of 2011, my doctor and I pinpointed the proper dosage of a prescription for this condition. After the spring semester of 2012 my departmental head Bruce Carroll suggested that I seek accommodations through the DRC. Just before fall 2012 I began receiving a double exam time accommodation (at the end of summer classes).

If you are petitioning for a medical drop(s), how did the presenting issues negatively impact the specific course(s)? Please also comment on how the medical issue(s) did not impact your others courses that semester.

In the majority of engineering courses at UF, the grade is highly dependent on exam scores. These exam scores usually make up 70% or more of an entire semester's grade. Without accommodations like I am now receiving, my grades were severely impacted.

Name _________________________ UFID ____________________________

Page 4 of 5

If you are petitioning for a retroactive semester medical withdrawal, what prevented you from withdrawing before the end of the semester?

I believed that I was simply struggling with a very difficult major (mechanical engineering). It was well after being tested by the wellness center and beginning to take medication/receiving accommodations, when I was informed about retroactive withdrawal and how it could be applicable to my situation.

Additional Comments:

Steps for Completing a Current Semester Medical Withdrawal/Drop Petition: 1. 2.

Page 5 of 5

3.

Withdraw from all courses or select courses by the listed university withdrawal/drop deadline. To withdraw from all courses, please fill out the Application To Withdraw From All Courses form. To drop an individual course(s), please meet with your academic advisor before the drop/withdrawal deadline. Complete the entire Medical Withdrawal Petition Questionnaire and provide current medical documentation to substantiate or support the statement in your petition. If you are petitioning for a current semester medical drop, please make sure to submit an Instructor Recommendation Form for each course that you are petitioning. Submit your documentation to the Dean of Students Office in one of the following ways: Deliver in person to the Dean of Students Office in Peabody 202 Mail to: Medical Withdrawal Process ~ Dean of Students Office ~ Peabody 202 ~ P.O. Box 114075 Gainesville, FL 32611 Fax to 352-392-1216 Email to dsocares@dso.ufl.edu

Steps for Completing a Retroactive Semester Medical Withdrawal/Drop Petition: 1. 2. 3. Complete the entire Medical Withdrawal Petition Questionnaire and provide current medical documentation to substantiate or support the statements in your petition. Submit an Instructor Recommendation Form for each course that you are petitioning. Submit your documentation to the Dean of Students Office in one of the following ways: Deliver in person to the Dean of Students Office in Peabody 202 Mail to: Medical Withdrawal Process ~ Dean of Students Office ~ Peabody 202 ~ P.O. Box 114075 Gainesville, FL 32611 Fax to 352-392-1216 Email to dsocares@dso.ufl.edu

Medical Documentation Guidelines: Medical documentation should be prepared on letterhead, typed, dated, and bear the signature of the evaluator. Please make sure the documentation includes the name, title, contact information, and professional credentials of the evaluator, and the information below regarding the medical reason for the petition: Physical Reasons: a. A statement of condition as a medical diagnosis. b. Include the date of diagnosis and the date of last contact with this student. Please indicate whether the condition is permanent or temporary (prognosis). c. A description of the procedures (e.g. clinical/diagnostic interview, rating scales, physical examination) that were used to assess/diagnose the medical condition. d. A description of the symptoms that meet the criteria for diagnosis with the approximate date of onset. e. A list of any medications or other treatments, including any possible medication/treatment side effects. f. Any additional medical information that may be relevant to the petition. Psychological Reasons: a. A statement of psychiatric, psychological, or learning impairment. Please provide a DSM diagnosis, if applicable. b. Date of diagnosis, dates of attendance, and date of last contact with this student c. A description of the symptoms that impacted the entire semester or individual courses d. A list of any medications/treatments the student is currently utilizing, including any possible side effects e. Any additional medical information that may be relevant to the petition. Death of Immediate Family Member: a. Death Certificate b. Obituary Other: a. Police Report b. Statement from a victim advocate c. Medical documentation from an immediate family members medical provider